Provider First Line Business Practice Location Address:
1100 N GARDNER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47170-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-752-5065
Provider Business Practice Location Address Fax Number:
812-752-1320
Provider Enumeration Date:
07/02/2006